Decreasing length of stay in bariatric surgery: The power of suggestion.

OBJECTIVE: Enhanced recovery has been utilized to decrease length of stay and cost in bariatric surgery. We have recently focused efforts on pre-operative education with regards to discharge on the first post-operative day. The aim of this study was to determine the effectiveness of pre-operative education on discharge timing and readmission rates. METHODS: A retrospective review was conducted after revising discharge expectation education. Patients undergoing first time bariatric operations were included. Early group education focused on average patient stay of 2 postoperative days. Revised education informed patients they could go home on the first post-operative day. RESULTS: A total of 125 patients met inclusion criteria. Implementation of preoperative education was associated with a decrease in mean LOS and greater percentage of patients discharged on post-operative day one. There was no difference in readmission and complication rates. CONCLUSION: Effective pre-operative education can decrease length of stay in first time laparoscopic bariatric surgery.

Congenital duodenal anomalies in the adult.

BACKGROUND: Duodenal anomalies are defects in embryologic development and usually present as gastric outlet obstruction in infancy or early childhood. Occasionally, they remain asymptomatic until adulthood and, because they are unusual, may not be diagnosed. HYPOTHESIS: Based on current experience and review of the literature, recognition of diagnosis and the preferred methods of treatment of duodenal anomalies can be recommended. DESIGN: Retrospective study of congenital duodenal anomalies in adults. SETTING: Tertiary care university medical center. PATIENTS: Twenty-nine patients were observed and treated between 1983 and 1999 (19 women and 10 men; mean +/- SD age, 52 +/- 16 years). Twenty patients had duodenal webs, 7 had annular pancreata, and 2 had both. Nausea, vomiting, abdominal pain, and weight loss were predominant symptoms in all groups. Peptic ulceration occurred in 13 of 20 patients with webs but in none of those with annular pancreata or combined anomaly. MAIN OUTCOME MEASURES: Surgical outcomes including postoperative complications, deaths, and resolution of preoperative symptoms. RESULTS: The treatment for patients with duodenal webs was transduodenal web excision and duodenoplasty in 19 of 22. Patients with annular pancreata were treated by transection of the annulus and duodenoplasty (n = 4) and proximal duodenal bypass (n = 3). There were no operative deaths, but 44% of patients had some complications. No pancreatic fistulas occurred in patients who had division of an annular pancreas. Outcome was considered excellent or good in 17 of 20 patients with duodenal webs, 4 of 7 with annular pancreata, and 2 of 2 with the combined anomaly. CONCLUSIONS: Duodenal anomalies are rare in adults. Duodenal webs are best managed by transduodenal excision and duodenoplasty. Annular pancreas is generally best treated by duodenal bypass to the distal duodenum or the jejunum. Annulus division can be carried out if the annulus is extramural, without duodenal stenosis, and if access to the pancreaticobiliary sphincters is necessary.

Regional differences in phorbol 12-myristate 13-acetate stimulation of PDGF production in the normal canine aorta.

OBJECTIVE: Platelet-derived growth factor (PDGF) is a potent smooth muscle cell mitogen implicated in the development of intimal hyperplasia and atherosclerosis. A regional variation in canine aortic production of PDGF (greater in the distal than in the proximal aorta) was demonstrated previously in organ culture. The response of aortic segments in organ culture, as well as of aortic endothelial cells and smooth muscle cells, to stimulators of PDGF secretion-phorbol 12-myristate 13-acetate (PMA) and thrombin-was assessed to elucidate whether these regional variations were due to intrinsic differences in the abilities of cells to produce PDGF. METHODS: Proximal and distal aortic segments were removed from 10 dogs and placed in organ culture, then treated with PMA or thrombin for 72 hours. PDGF in the conditioned media was measured by radioreceptor assay. RESULTS: PDGF production in the distal, unstimulated aorta was 2.5-fold higher than that in the proximal aorta (P <.05). Treatment of the proximal aorta with 10 nmol/L and 100 nmol/L PMA increased PDGF production twofold and threefold, respectively, whereas no increase with PMA treatment was seen in the distal aorta. After thrombin treatment, no increase in PDGF production was noted in the proximal aorta and only a minimal increase was noted in the distal aorta. Endothelial cells and smooth muscle cells (n = 6) were cultured from four aortic segments (ascending thoracic, descending thoracic, abdominal, and infrarenal) and treated with PMA. PDGF production by unstimulated endothelial cells from the infrarenal aorta was 2.5-fold higher (P <.01) than that from the ascending thoracic aorta. With PMA treatment, PDGF secretion increased in endothelial cells from all segments, the greatest percentage increase being observed in the proximal segments. Thrombin also increased PDGF release from endothelial cells, but with no regional variation. Unstimulated smooth muscle cells did not exhibit regional variation in PDGF production and did not increase PDGF secretion after treatment with PMA or thrombin. CONCLUSIONS: These findings suggest that endothelial cells in the aorta may have a differential capacity to produce PDGF in response to stimulants, reflecting intrinsic differences in endothelial cells from the proximal aorta versus the distal aorta, and this may account in part for the propensity of the distal aorta to develop atherosclerosis.

Primary bile reflux gastritis: which treatment is better, Roux-en-Y or biliary diversion?

Primary bile reflux gastritis is an unusual and elusive problem. Postgastrectomy bile reflux has been long recognized and treated variously with Roux-en-Y gastrojejunostomy, Braun enteroenterostomy, and Henley jejunal interposition. All of these procedures have been fraught with postoperative side effects, the worst of which is stasis. A new procedure utilizing biliary diversion has been proposed to divert bile from the gastric lumen without vagotomy or gastric resection. This procedure was used for 16 patients with diagnosed bile reflux, and results were compared with those of a previous group of 21 patients who had been treated with Roux-en-Y gastrojejunostomy. The patient groups were similar in age, sex, weight, symptoms, and results of investigative studies. The earlier group all had vagotomy, antrectomy, and gastrojejunal anastomosis to a 45-cm Roux limb. The later group all had an end-to-side choledochojejunostomy to a 45-cm Roux limb, taken 45 cm from the ligament of Treitz. The patients in the bile diversion group had fewer complications and shorter hospital stays. In addition, they had few postoperative complaints, no further operations for either bile reflux or upper gastrointestinal stasis, and no long-term deaths due to gastrointestinal problems or malnutrition. Their eventual postoperative gastric emptying improved significantly when compared with the Roux-en-Y patients, suggesting that the dysmotility observed preoperatively may well have been a result of the bile injury to the stomach, rather than an underlying gastric dysmotility.

Classification and management of perforations complicating endoscopic sphincterotomy.

BACKGROUND: The management of perforations after endoscopic sphincterotomy (ES) is controversial. The purpose of this study was to analyze the treatments and outcome of patients with ES perforations. METHODS: Between January 1994 and July 1998, in a series of 6040 endoscopic retrograde cholangiopancreatographies, 2874 (48%) ESs were performed: 40 patients (0.6%) with perforation were identified and retrospectively reviewed. RESULTS: All patients (n = 14) with guidewire perforation (group I) were recognized early, managed medically, and discharged after a mean hospital stay of 3.5 days. Twenty of 22 patients with periampullary perforation (group II) were identified early; 18 patients (90%) had aggressive endoscopic drainage, and none required operation. Of the 2 patients identified late, 1 patient required operation and subsequently died. Mean hospital stay for this group was 8.5 days. Only 1 of 4 patients with duodenal perforations (group III) was identified early; all required operation; 1 patient died, and the mean hospital stay was 19.5 days. CONCLUSIONS: ES perforation has 3 distinct types: guidewire, periampullary, and duodenal. Guidewire perforations are recognized early and resolve with medical treatment. Periampullary perforations diagnosed early respond to aggressive endoscopic drainage and medical treatment. Postsphincterotomy perforations diagnosed late (particularly duodenal) require surgical drainage, which carries a high morbidity and mortality rate.

Adenosquamous carcinoma of the pancreas.

HYPOTHESIS: Adenosquamous carcinoma of the pancreas is a rare but particularly virulent variant of invasive ductal carcinoma. This review will demonstrate the aggressive biologic activity, histopathologic features, and DNA flow cytometric characteristics of this aggressive lesion. In addition, the outcome is less favorable than in other pancreatic neoplasms, in spite of aggressive surgical and postoperative adjuvant therapy. DESIGN: A retrospective review of 6 patients treated during an 8-year period. SETTING: A major urban university tertiary referral hospital. PATIENTS: There were 6 patients with this unusual tumor seen between 1990 and 1998. There were 4 men and 2 women, all white, with a mean+/-SD age of 63.5+/-14.7 years. Symptoms were similar to those in patients with more common pancreatic malignant neoplasms. RESULTS: Four patients with tumors in the head of the pancreas had pancreatoduodenectomy, and 2 with body and or tail lesions had distal pancreatectomy and splenectomy. Pathologically, all the tumors were poorly differentiated and aneuploid, and 5 of the 6 were locally metastatic. All but 1 patient had postoperative complications, but there were no operative deaths. One half of the patients received postoperative adjuvant chemotherapy and radiation therapy. Only 1 patient is still alive at 9 months after surgery, but has known residual cancer around his portal vein noted during palliative distal pancreatectomy. CONCLUSIONS: Adenosquamous carcinoma of the pancreas is an uncommon variant of exocrine pancreatic neoplasm. It is characterized by an admixture of adenomatous and squamous cell elements and demonstrates aggressive biologic behavior. This series of 6 patients is similar to the 134 cases reported since 1907, in that survival is short despite aggressive surgical therapy. Few patients with this disease live more than 1 year. Aggressive therapy should be tempered by the realization of the uniform poor prognosis associated with this malignant neoplasm.

Contemporary treatment strategies for external pancreatic fistulas.

BACKGROUND: Optimal treatment strategies for patients with external pancreatic fistulas have evolved with improved radiographic imaging and the development of transpapillary pancreatic duct stents. The aim of this study was to examine factors affecting fistula closure and develop a classification scheme to guide therapeutic interventions. METHODS: Retrospective chart review was made of all patients with external pancreatic fistulas treated at our institution from January 1991 to January 1997. Side (partial) fistulas maintained continuity with the gastrointestinal tract; end (complete) fistulas had no continuity with the gastrointestinal tract. RESULTS: Postoperative side fistulas resolved with medical treatment in 13 (86%) of 15 patients after a mean of 11 weeks of conservative management. Inflammatory side fistulas resolved with medical treatment in only 8 (53%) of 15 patients after a mean of 22 weeks; those that did not close initially did so with transpapillary stenting. End pancreatic fistulas never closed with medical treatment and were unable to be stented; therefore internal drainage or pancreatic resection was necessary to achieve closure. There were no differences in sepsis rates, Acute Physiology and Chronic Health Evaluation II scores, fistula site, total parenteral nutrition, somatostatin treatment, or initial fistula output between groups. CONCLUSIONS: Classifying external pancreatic fistulas as to their pancreatic duct relationship and cause provides important prognostic and therapeutic information.

Mucin-hypersecreting intraductal neoplasms of the pancreas: a precursor to cystic pancreatic malignancies.

BACKGROUND: Muncin-hypersecreting intraductal pancreatic neoplasms were first described in 1982 and have been observed in increasing numbers since. They are observed primarily by endoscopic retrograde cholangiopancreatography (ERCP) and are characterized by an intraductal papillary neoplasm that secretes thick mucin, causing pancreatic duct dilatation and obstructive pancreatitis. METHODS: Twenty patients are presented, 14 male and six female, with an average age of 59 +/- 11 years. All patients presented with abdominal pain, and most had nausea and vomiting, weight loss, and documented pancreatitis. Of the preoperative studies, ERCP was positive in all patients. Computed tomography scan, endoscopic ultrasonogram, and cytologic findings were less sensitive. Tumor markers were only positive in one patient. All 20 patients were treated surgically. Nine underwent Whipple procedure, one patient had a total pancreatectomy, and nine had distal pancreatic resections. The first patient in the series did not have a pancreatic resection, and his disease evolved into a lethal cystadenocarcinoma causing his death 99 months later. RESULTS: Histopathologic findings were interpreted as borderline malignant in 17 of the 20 patients, and three patients had evidence of invasive adenocarcinoma. Two of these three patients had nodal or distant metastases at the time of diagnosis, and all three died of adenocarcinoma. Seventeen of the patients are alive and well, although two of three with positive pancreatic margins have had recurrent symptoms and have been successfully reresected. CONCLUSIONS: The mucin-producing intraductal papillary tumor of the pancreas is a newly described variant of pancreatic cancer. It presents with symptoms of pancreatitis and has a progressive but more indolent course than the more lethal invasive ductal cancers. Patients with unexplained pancreatitis should undergo ERCP investigation, and aggressive surgical therapy should be carried out because the prognosis for this lesion, when appropriately treated, is more favorable than the usual pancreatic cancer.

Nonfunctioning islet cell tumors of the pancreas: a difficult diagnosis but one worth the effort.

Islet cell tumors of the pancreas usually secrete gastroenteropancreatic peptides causing well-recognized clinical syndromes. Description of these syndromes and the identification of the responsible hormones by radioimmunoassay has led to a better understanding of neuroendocrine regulatory function. More recently, similar tumors have been seen that contain various peptides on immunohistochemical stain but do not secrete these substances sufficiently to cause clinical symptoms. Nonetheless, they have the same malignancy and metastatic rate as most of the functional tumors. Between 1972 and 1996, 44 patients with islet cell tumors have been treated at the Indiana University Medical Center Hospital, and of these 14 have been nonfunctional. Preoperative imaging studies, such as CT scan and endoscopic ultrasound, were able to visualize a lesion but not to make the specific diagnosis, even with fine-needle aspiration. Pancreatic ductal preservation on endoscopic retrograde cholangiopancreatography with CT evidence of a mass should arouse suspicion of an islet cell tumor. Once discovered, all but 1 of the 14 patients has under gone resective therapy, with only 1 postoperative death. Treatment has been aggressive, with 11 of the 13 resected patients undergoing pancreaticoduodenectomy, and 2 others distal pancreatectomy. Four of the seven patients with positive lymph node metastases are dead, while all patients with negative nodes are still alive. Thus far, 10 of the original 14 patients are alive, surviving an average of 32.7 months, with a median survival of 31.1 months. Because these tumors have a better overall prognosis, vigorous attempts at total or subtotal resection should be carried out, since the long-term survival is enhanced by tumor bulk reduction or curative resection when possible.

The role of pancreatic resection in the treatment of pancreatic pseudocysts.

Complicated pancreatic pseudocysts, including multiple pseudocysts, those that have failed prior internal or external drainage, those with associated biliary or pancreatic duct strictures, and those where the diagnosis of cystic neoplasm cannot be excluded, pose unique problems in terms of treatment by standard internal or external drainage techniques. In the series reported herein, pancreatic resection (pylorus-sparing pancreaticoduodenectomy or distal pancreatectomy) was used to treat patients with these complicated pseudocysts resulting in a 59% morbidity rate, 3% mortality rate, and 6% recurrence rate. Results from a collective series of 152 patients from the literature support these findings. Although pancreatic resection has a limited role in the management of patients with uncomplicated pancreatic pseudocysts, it is the treatment of choice in patients with complicated pancreatic pseudocysts.

Biliary diversion. A new method to prevent enterogastric reflux and reverse the Roux stasis syndrome.

OBJECTIVE: To design an operation to prevent enterogastric reflux of bile that will not interfere with gastric or proximal intestinal motility and that will be applicable in patients with primary alkaline reflux gastritis, various prior ulcer operations, and previous corrective operations for enterogastric reflux. DESIGN: A nonrandomized, prospective review of 27 patients with enterogastric reflux operated on between 1991 and 1995. SETTING: A midwestern medical school and 400-bed tertiary referral center, adult hospital. PATIENTS: Twenty-seven patients with symptoms compatible with enterogastric reflux, primary or secondary to ulcer operations, or with Roux-en-Y limb stasis following attempts to correct alkaline reflux gastritis. INTERVENTIONS: An operation designed to reestablish gastroduodenal continuity by converting previous procedures such as Billroth II gastrectomy and Roux-en-Y gastrojejunostomy to a Billroth I gastroduodenostomy, and by diverting bile away from the stomach by end-to-side choledochojejunostomy by means of a Roux-en-Y limb of 35 to 40 cm. MAIN OUTCOME MEASURES: Resolution of the preoperative symptoms of pain, nausea, and bilious vomiting in patients with enterogastric reflux, and elimination of the Roux stasis syndrome as well as prevention of future enterogastric reflux in patients undergoing conversion from Roux-en-Y to Billroth I. Serial evaluation of gastric emptying after conversion to a Billroth I configuration to determine whether dysmotility is improved or eliminated. RESULTS: Symptoms were completely resolved in 22 of the 26 surviving patients, with follow-up of 6 months to 4 years. None of the 26 patients have had any bilious vomiting postoperatively. Roux-en-Y stasis has been corrected when due to a mechanical problem (eg, strictures, marginal ulcers), although thus far normal gastric emptying has not been observed in all of these multiply surgically treated patients. CONCLUSIONS: Enterogastric reflux is common following most ulcer operations. Attempted correction of this problem may result in other difficulties, including delayed emptying due to Roux-en-Y stasis. The fact that most patients with enterogastric reflux are female suggests that this condition is related to disordered motility; therefore, vagal interruption and major gastric resections should be carefully considered to avoid future disabling problems.

The role of flow cytometric DNA analysis in determining prognosis of resectable ductal adenocarcinoma of the pancreas.

Carcinoma of the pancreas is a leading cause of cancer mortality in the United States. Improvement in prediction of survival is needed. Flow cytometric analysis as a prognostic tool has produced conflicting results. We retrospectively analyzed the clinicopathologic features, operative factors, and outcome of 39 curative resections for ductal adenocarcinoma of the head of the pancreas performed at Indiana University Medical Center between 1989 and 1994. The group was composed of 20 females and 19 males. Procedures performed were Whipple without vagotomy (n = 5), Whipple with vagotomy (n = 19), pylorus-preserving Whipple (n = 12) and total pancreatectomy (n = 3). Thirty-two tumors were suitable for DNA analysis. Of the 32 patients with flow cytometric data, 33 per cent (3/9) of living patients and 39 per cent (9/23) of deceased patients had aneuploid tumors (P = 0.999). The average S-phase for living patients was 8.3 per cent +/- 3.8 per cent, and 16.1 per cent +/- 13.6 per cent for deceased patients (P = 0.115). In the multivariate analysis, only lymphatic invasion (P = 0.015) and alkaline phosphatase level (P = 0.024) predicted poor survival. Our data show no correlation between flow cytometric DNA ploidy, S-phase analysis, and prognosis in patients undergoing curative resection for ductal adenocarcinoma of the pancreatic head.

Inhibition of smooth muscle cell proliferation and migration in vitro by antisense oligonucleotide to c-myb.

PURPOSE: Smooth muscle cell (SMC) migration and proliferation are prominent features of intimal hyperplasia. Previous studies have shown that inhibition of c-myb inhibits arterial SMC proliferation. Our goal was to evaluate the effect of an antisense oligonucleotide targeted to c-myb on the proliferation and migration of SMC explanted from synthetic vascular grafts. METHODS: SMCs were enzymatically removed from aortas and Dacron grafts explanted from dogs (n = 5). For proliferation studies, quiescent SMCs were incubated with either 0.0, 0.5, 5.0, or 10.0 microM antisense (GTGTCGGGGTCTCCGGGC) or sense (GCCCGGAGACCCCGACAC) oligonucleotides to c-myb. Proliferation was measured after 24 hours by incorporation of [3H]thymidine. Migration was assessed 24 hours after a razor injury. RESULTS: Antisense to c-myb consistently inhibited proliferation and migration of both native aortic and graft SMCs in a dose-dependent fashion. At a concentration of 10 microM antisense oligonucleotide, aortic and graft SMC proliferation rates were 32% +/- 20% and 56% +/- 9% of control samples, respectively. At 25 microM antisense, the number of migrating aortic and graft SMCs decreased to 41.9% +/- 26.8% and 51.9% +/- 34.1% of control samples, respectively. CONCLUSIONS: Our results suggest that antisense oligonucleotides to c-myb may be useful in the inhibition of SMC proliferation and migration associated with development of intimal hyperplasia.

Nonocclusive mesenteric ischemia remains a diagnostic dilemma.

BACKGROUND: Despite reports of low mortality and high bowel-salvage rates in nonocclusive mesenteric ischemia (NOMI), our experience has been much less favorable. This study analyzes our experience with NOMI. PATIENTS AND METHODS: A retrospective chart review (1979 to 1992) identified 113 patients with acute mesenteric ischemia, of whom 13 (12%) met our criteria for NOMI. RESULTS: Patients were grouped into early and late presenters. The 5 early presenters were women, younger (mean age [+/- SD] 50 +/- 5.8 years), with no risk factors, and had vague symptoms leading to a delay in diagnosis. The 7 late presenters were older (mean age [+/- SD] 63 +/- 5.3 years) with identifiable risk factors; all had bowel infarction at the time of initial diagnosis. CONCLUSIONS: Vague symptoms and a wide range of patients at risk make early diagnosis of NOMI uncommon. In the absence of early diagnosis, bowel resection with its high morbidity and mortality remains the only applicable treatment option in the vast majority of patients.

Regional differences in platelet-derived growth factor production by the canine aorta.

Platelet-derived growth factor (PDGF) is a potent mitogen and chemotactic agent which may be involved in the formation of proliferative lesions of the arterial system, such as intimal hyperplasia and atherosclerosis. To examine the regional variation in vessel wall production of this mitogen, PDGF production and PDGF A chain mRNA expression by normal arterial wall was studied as a function of vessel location. PDGF production by canine aortic segments was measured after 72 h in organ culture, revealing significantly more PDGF produced by the distal compared to proximal aorta at 77 +/- 10 versus 14 +/- 6 pg/cm2/72 h (p<0.05). Endothelial cells (EC) and smooth muscle cells (SMC), isolated from analogous aortic sites, were grown in tissue culture and the conditioned medium was assayed for PDGF. EC in vitro demonstrated a similar geographic trend in PDGF production (distal=1,501 +/- 389 pg/microgram DNA/72 h, proximal=759 +/- 230 pg/microgram DNA/72 h; p=0.17). PDGF production by SMC in cell culture had a similar pattern with cells from the distal aorta producing 58 +/- 28 pg PDGF/microgram DNA/72 h, compared to cells from the proximal aorta producing 37 +/- 15 pg PDGF/microgram DNA/72 h (p=0.13). Freshly harvested EC and SMC, isolated from the same aortic sites, were subjected to quantitation of PDGF mRNA levels using a coupled reverse transcriptase and polymerase chain reaction amplification method, with glyceraldehyde-phosphate dehydrogenase (GAPDH) as a control. The ratio of PDGF A chain:GAPDH mRNA was significantly greater in distal aortic SMC, 2.30 +/- 0.99, compared to proximal aortic SMC, 1.27 +/- 0.46 (p=0.05), but was not significantly different between proximal and distal aortic EC (p=0.86). These findings demonstrate significant regional differences in PDGF production in the normal canine aorta. Additionally, SMC are implicated as a significant contributor to the regional variation in PDGF production.

Surgical treatment of obstructive pancreatitis.

BACKGROUND: Unlike chronic calcific pancreatitis, obstructive pancreatitis occurs as a consequence of an obstruction or stricture in the main pancreatic duct. The purpose of this paper is to identify the best method of surgical treatment for patients with obstructive pancreatitis. METHODS: Retrospective analysis of 224 patients surgically treated for chronic pancreatitis during a 7-year period (1988 through 1994) identified 23 patients with obstructive pancreatitis. Patients were classified by surgical treatment into pancreaticoduodenectomy (five patients), side-to-side pancreaticojejunostomy (nine patients), or distal pancreatectomy (nine patients) groups and analyzed. RESULTS: Despite similar demographics, patients treated with distal pancreatectomy had significantly better outcomes (seven of nine) than those treated with either pancreaticoduodenectomy (zero of four) or side-to-side pancreaticojejunostomy (two of eight) at a mean follow-up of 26 months (chi-squared, p = 0.009). Multivariate analysis revealed stricture location, cause of pancreatitis, maximal duct dilatation, exocrine insufficiency, or continued alcohol intake had no influence on surgical outcome in this series (p = 0.698, logistic regression analysis). CONCLUSIONS: At 2 years of follow-up, distal pancreatectomy provided superior relief from pain and recurrent pancreatitis compared with pancreaticoduodenectomy or side-to-side pancreaticojejunostomy. Obstructive pancreatitis is best treated by distal rather than proximal pancreatic resection or drainage.

Classification and treatment of local septic complications in acute pancreatitis.

BACKGROUND: An international symposium on acute pancreatitis recently developed a clinical classification system for severe acute pancreatitis that classifies all local septic complications into three groups: infected necrosis (IN), sterile necrosis (SN), and pancreatic abscess (PA). Despite the appeal of having three distinct, well-defined labels for this complex process, the clinical utility of this schema has yet to be determined. The purpose of this study was to investigate the prognostic and therapeutic utility of applying this clinical classification system to a large group of surgical patients with local septic complication from acute pancreatitis. PATIENTS AND METHODS: We reviewed the cases of 62 patients with complicated pancreatitis, classifying them into IN (n = 20), SN (n = 14), or PA (n = 28) groups. Ranson's score, APACHE II score, and computed tomography grading were calculated within the first 48 hours of admission. Information on patient demographics, etiology of pancreatitis, operative procedures, timing of intervention, bacteriology, blood loss, intensive care unit days, ventilator days, and morbidity and mortality were also accrued and analyzed. RESULTS: Despite similar demographics and etiology of pancreatitis, patients with necrosis, both IN and SN, were more critically ill than were patients with PA (APACHE II score > 15, 21% versus 0%, respectively), required earlier operative intervention (mean 14 days versus 29 days, P = 0.02), required necrosectomy with drainage (65% versus 4%, P < 0.001) rather than simple drainage (3% versus 86%, P < 0.001), more reoperations (2.3 versus 1.1, P < 0.05), and had a significantly higher mortality rate (35% versus 4%, P < 0.05). In addition, patients with IN required significantly more hospital days, ventilator days, and blood transfusions than either patients with SN or PA (P < 0.05). CONCLUSIONS: We conclude that this classification system allows for the stratification of patients into three distinct groups--infected necrosis, sterile necrosis, and pancreatic abscess--and has both therapeutic and prognostic usefulness.